How does chronic pain management work? A self concept hypothesis

“What DOES change is [people’s] self efficacy or belief that they CAN do what’s important in their lives – by hook or by crook. And even more importantly, they have something to DO that’s important to them. Maybe something that hasn’t been studied in sufficient detail is what a person wants to be able to do, what’s their motivation, what are their valued occupations? That’s a hypothesis about therapeutic change I think we need to ponder.”

Later in the comments I mentioned the idea of renegotiating self concept – that part of learning to live well with chronic pain is the process of integrating the reality of on-going pain and associated limitations within their “understanding of how he or she responds in situations and the roles he or she expects to fulfil” (Baumeister, 1997; Christiansen, 1999). Self-concept is a predictive process where the knowledge a person has about his or her personality traits, roles, and relationships guides their actions so that they present consistently across social and private contexts.

So self concept is “the person I am”. Several authors have described chronic pain as a “biographical disruption” that forces individuals to reconsider their past, present and future, often creating a discrepancy between the self-concept before pain and the current self (Asbring, 2001; Richardson, Ong, & Sim, 2006; Wilson, 2007). To accommodate chronic pain within the self concept means people need to incorporate an understanding of the new current self in a way that can retain as much of the past self as possible, without placing unsustainable demands on the future self. People who cope well with pain develop a self-concept in which the effect of pain is assimilated without compromising critical values in their lives, even though it may influence how these are enacted.

What this means is that people who cope well with pain identify the important values they hold (parts of self), let go of old parts of themselves they can’t continue to achieve, and find ways of ensuring the parts of themselves that they do value very highly can still be done.

John Quintner suggested that programmes that help people cope with their pain provide people with hope. I agree. I think that by helping people see that they can still retain essential parts of their concept of who they are, they can begin to see that life CAN continue to have some of the good things they really value.

Some of the mechanisms that I think might be involved in helping people renegotiate their self concept are:

engaging in occupations (activities, roles that are individual and unique to them) as part of learning to make sense of their pain

this helps to make their pain less threatening, more predictable

and thus they’re more able to account for the effects of pain on what they want to do

People don’t only learn by doing things themselves, they also learn by seeing other people do things. This means that when people see a famous athlete or actor identifying with something like depression, for example, people with depression can gain hope that they too can still achieve despite their depression. In chronic pain management, people attending a group programme watch one another do things that they have also struggled with – and this provides both a model as to how this can be done, but also something to aspire to. This increases self efficacy because instead of seeing how “experts” (ie professionals) suggest they do things, they see people “like me” doing things.

If learning to live well with pain is partly about developing a new sense of self, then acceptance also involves letting go of things that can no longer be sustained (the past self) while holding onto important aspects of this self that can continue in a sustainable way into the future. This is something we all need to learn to do as we grow older. Usually it’s a gradual process, and most of us are sad to recognise that we’re aging, but also positive in that we’re moving towards new things that continue to add to our self concept. For people who develop chronic pain, it can be a profound change.

Letting go of the desire to “go back to normal” is incredibly hard. It won’t happen if a new opportunity to “go back to normal” keeps on being offered. And this is the tragedy of repeated attempts to find a complete cure, because it stops people being able to let go of things that may be unsustainable, keeps them in a sort of stasis while their life is focused on pain. And for many types of pain, there is no complete cure – even very successful interventions rarely completely abolish pain.

Hope, for people with chronic pain, involves more than taking all the pain away. It needs also to restore their confidence that they can be the person they want to be, to fit their self concept. This is why return to work for people with chronic pain needs to address issues of the person feeling unreliable (“how can I go to work if I can’t go every day because of my pain?” “who would employ me when I can’t work the way I used to?”), of being able to present themselves as an asset to an employer, where chronic pain isn’t a liability but can be an asset. Because most people want to be seen as competent, reliable, and contributing within a work environment – and until they can see how these things can be achieved despite their pain, it’s going to be hard for them to convince an employer.

I think that learning to be flexible in terms of how to go about achieving something important might be the biggest factor in how chronic pain management programmes work. And I think the process is about renegotiating a self concept that allows this flexibility to occur, and maybe by helping people identify the values that underpin important occupations we might be able to support them to find new ways to express those values.